腹腔镜治疗小儿斜疝97例

目的探讨腹腔镜治疗小儿斜疝的临床价值. 方法单侧斜疝72例,双侧斜疝25例,采用自制缝合套管针行内环口腹膜下环周缝合,达到疝囊高位结扎. 结果 97例手术成功.平均手术时间:单侧10 min,双侧16 min.术后住院1 d,无并发症.70例随访2～60个月,平均31个月,无复发. 结论腹腔镜治疗小儿斜疝安全可行,创伤小,并发症少,恢复快,复发率低.     

经腹腔腹膜前补片腹腔镜腹股沟疝修补术170例报告

目的:探讨经腹腔腹膜前补片腹腔镜腹股沟疝修补术(TAPP)治疗腹股沟疝的方法与经验。方法:1995年6月~2005年7月应用TAPP治疗170例腹股沟疝,采用网状补片常规固定、腹膜常规连续缝合关闭等方法。结果:170例手术均获成功,无中转开放手术,平均手术时间52.5(40~120)m in,术后平均住院4.5d。术后随访1~11年,1例直疝复发。结论:TAPP是一种安全可靠的疝修补术,具有复发率低等优点,特别适于复发疝、双侧疝等,值得推广应用。     

Laparoscopic inguinal hernia repair; experience with 874 children

Background

Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the open procedure. It is gaining popularity with more and more studies supporting its feasibility, safety, and efficacy. This is a retrospective study to present our experience with children who underwent LIHR.

Patients and methods

A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. They were 703 boys and 171 girls. Their mean age was 2.9 ± 2.1 years (range, 6–108 months). Six-hundred and twenty four opened internal inguinal rings (IIRs) were closed by transperitoneal purse string suture technique (TPP) and 560 opened IIRs were closed by percutaneous purse string suture with lateral umbilical ligament enforcement using Reverdin Needle (RN) technique.

Results

All cases were completed laparoscopically without conversion. There were no serious intraoperative complications. Mean operating time, in TPP technique, was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes for bilateral inguinal hernia, while the mean operating time, in RN technique, was 8.7 ± 1.18 minutes for unilateral and 12.35 ± 2 minutes for bilateral hernia repair. The contralateral patent processus vaginalis (PPV) was present in 176 (20% of cases). Follow-up to date is 10–140 months (mean 80 ± 2.1 months). In the early stage of this study, the recurrence rate was 1.13%. In the last 450 cases, no recurrence occurred. Hydroceles occurred in 0.58% and no testicular atrophy or iatrogenic ascent of the testis.

Conclusions

LIHR can be a routine procedure with results comparable to those of open procedures. Both recurrence and operative time are nearly equal or even less than that for the open procedure after gaining a learning curve and modifications of the techniques.     

腔镜下腹股沟疝修补术与常规手术对比研究

目的探讨腔镜下腹股沟疝修补术的可行性、安全性。方法将腔镜下疝修补手术260例(腔镜组)与常规疝修补手术250例(常规组),在手术时间、出血量、镇痛剂应用例数、下床活动时间、住院时间、住院费用以及并发症进行对比分析。结果腔镜组与常规组在出血量(mL)、手术时间(min)、镇痛剂应用例数(n)、住院时间(d)、下床活动时间(h)、住院费(元)、并发症(n)分别为10.1±3.3、15.3±4.2,差异有统计学意义(P<0.05);60.2±10.5、50.4±12.1,差异有统计学意义(P<0.05);4、38,差异非常显著(P<0.01);6.5±2.3、10.2±2.5,差异有统计学意义(P<0.05);18.5±5.3、38.6±6.5,差异非常显著(P<0.01);6909.8±1235.2、5841.1±1258.6,差异有统计学意义(P<0.05);1、13,差异非常显著(P<0.01)。结论腔镜下腹股沟疝修补术具有创伤小、恢复快、效果佳等优点,是一种安全可行的微创伤治疗方法。     

Laparoscopic inguinal hernia repair in children

Childhood inguinal hernia is a result of a congenital patent processus vaginalis. In order to prevent strangulation of viscera trapped in the defect, surgery is necessary. Conventional operation for childhood inguinal hernia involves the use of a skin incision over the groin to dissect out the sac, taking care not to injure the adjacent important structures, namely the vas deferens and testicular vessels. The sac is then divided and the proximal end transfixed. With the advance in minimally invasive surgery, laparoscopic repair of childhood inguinal hernia has been attempted. Modification of the technique by injecting normal saline extraperitoneally before the purse‐string closure of the neck of the processus vaginalis has made the procedure safer. An advantage of the laparoscopic procedure is that it allows detection and repair of the contralateral hernia. Randomised controlled trials are still required to verify the suggested advantages of better cosmesis outcome and more efficient pain control. Long‐term follow up in a large‐scale study is also desirable, to evaluate the cost‐effectiveness and possible complications of this mode of treatment.      

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目的评价腹腔镜腹股沟疝修补术(LIHR)的临床疗效。方法回顾性分析2001年1月至2011年12月上海交通大学医学院附属瑞金医院普外科2056例(2473侧)行LIHR的临床资料,其中经腹腹膜前修补术(TAPP)874例(1005侧),全腹膜外修补术(TEP)1175例(1458侧),腹腔内修补术(IPOM)7例(10侧)。2473侧疝中,斜疝1481侧(59.9%),直疝525侧(21.2%),复发疝225侧(9.1%),复合疝206侧(8.3%),股疝36侧(1.5%)。疝分型:Ⅰ型疝95侧(3.8%),Ⅱ型疝995侧(40.2%),Ⅲ型疝1157侧(46.8%),Ⅳ型疝226侧(9.1%)。手术由同组医师完成,术式选择由术者决定,随访时间3～60个月(中位时间35个月)。结果 1例TAPP因腹腔广泛粘连中转为Lichtenstein术。病人术后无需应用镇痛剂。2周和4周内恢复非限制性活动率为99.0%和99.9%。共6例复发,复发率为0.24%。TAPP和TEP各3例复发。发生3例严重并发症,分别为戳孔疝、肠管损伤和机械性肠梗阻,其他并发症依次为血清肿129例(5.2%)、尿潴留34例(1.4%)、暂时性神经感觉异常26例(1.1%)、麻痹性肠梗阻3例(0.12%)。结论 LIHR是安全有效的手术,合理选择手术适应证和规范化操作可以获得良好的临床效果。     

Laparoscopic approach to incarcerated inguinal hernia in children

Purpose

The purpose of this study was to describe the laparoscopic approach to incarcerated inguinal hernia in children.

Methods

After unsuccessful manual reduction, 29 patients (aged 3 weeks to 7 years; median, 10 weeks; 44 boys, 15 girls) with incarcerated inguinal hernia underwent immediate laparoscopy. The hernial content was reduced in a combined technique of external manual pressure and internal pulling by forceps. The bowel was inspected, and the hernia was repaired.

Results

In all patients, the procedure was successful. No conversion to the open approach was required. Immediate laparoscopic herniorrhaphy in the same session was added. No complications occurred.

Conclusions

Laparoscopy allowed for simultaneous reduction under direct visual control, inspection of the incarcerated organ, and definitive repair of the hernia. Technically, it appears easier than the conventional approach because of the internal inguinal ring being widened by intraabdominal carbon dioxide insufflation. The hospital stay is shorter.     

Bilateral laparoscopic inguinal hernia repair in patients with occult contralateral inguinal defects

Background A high incidence of bilateral inguinal defects found on laparoscopic evaluation during hernia repair has been reported. However, expectation of bilateral inguinal defects in patients who are diagnosed with pure unilateral hernia might be underestimated. A prospective clinical study was performed to reveal a rate of contralateral occult defects in patients who were diagnosed with unilateral inguinal hernia prior to primary laparoscopic totally extraperitoneal (TEP) repair. Methods One hundred consecutive male patients with primary unilateral inguinal hernias were included in the study. Patients with known bilateral inguinal hernias as well as femoral, giant and combined hernias were excluded. All patients underwent TEP with exploration and evaluation of the contralateral groin. Results Median follow-up was 24 (4–46) months. Median age was 48 (18–73). Mean operative time was 42.2 (18–167) min. There were 78 (78%) patients with pure unilateral hernias and 22 (22%) patients with bilateral hernias whose contralateral inguinal defect or hernia was revealed only intraoperatively. Of those, 19 (86%) had right and 3 (14%) left occult defects. Minor complications occurred in 17 (17%) patients. There were no major complications. Two patients required a 23-hour stay in the hospital for urinary retention and hypoxia. Median period of returning to normal activity was 7 (5–14) days. There were two (2%) recurrences. Median period of returning to normal activity was 6.2 days after unilateral repair and 8.4 days after bilateral TEP. Conclusion This study revealed 22% occurrence of bilateral inguinal defects in the patients who are diagnosed with pure inguinal hernia before surgery, with higher incidence for those with left inguinal hernia. It appears that routine contralateral groin exploration and evaluation during TEP is valuable. Patients with occult bilateral hernias are benefit from bilateral TEP.     

腹腔镜经腹腔腹膜前疝修补术治疗腹股沟复发疝的临床体会

目的:总结腹腔镜下经腹腔腹膜前无张力疝修补术(transabdominal preperitoneal prosthetic,TAPP)治疗腹股沟复发疝的临床经验及效果.方法:回顾分析2009年3月至2012年1月为113例腹股沟复发疝患者行腹腔镜TAPP的临床资料,其中原位复发疝21例,再发疝92例.结果:112例顺利完成手术,1例中转开放手术.手术时间平均(55.3±16.5) min,平均住院(4.56±2.1)d.术后疼痛发生率4.4％,术后血清肿发生率14.2％,术后异物感发生率1.8％,尿潴留发生率6.2％,无切口感染及其他严重并发症发生.术后随访6 ～ 40个月,无再次复发.结论:腹腔镜TAPP治疗腹股沟复发疝具有患者创伤小、并发症少等优势,且后入路修补方式安全性较高,手术效果切实、可靠.     

腹腔镜下疝囊高位结扎术与传统术式比较

目的对比分析腹腔镜下疝囊高位结扎术与传统术式的手术效果。方法2002年7月～2004年12月,对94例小儿腹股沟斜疝及交通性鞘膜积液实施疝囊高位结扎术治疗,其中应用自制钩式雪橇针行腹腔镜下疝囊高位结扎术44例(腹腔镜组),传统的经皮切开手术50例(传统组)。结果腹腔镜组较传统组手术时间短[(18±5)minvs(27±8)min,t=-6.436,P=0.000],术后需用止痛药的例数少(5/44vs14/50,χ2=4.017,P=0.045),住院时间短[(3.2±1.2)dvs(7.3±1.9)d,t=-12.311,P=0.000],住院费用高[(2965.5±516.7)元vs(2389.7±372.3)元,t=-6.251,P=0.000]。结论腹腔镜下疝囊高位结扎术与传统术式相比,具有手术创伤小、术后疼痛轻、恢复快、住院时间短、无切口瘢痕等优点,是治疗小儿腹股沟斜疝及交通鞘膜积液较理想的手术方式。     

Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma

Background Seroma are common early postoperative complications encountered in laparoscopic inguinal hernia repair. Previous anecdotal evidence from our surgical practice suggested a lower incidence of postoperative seroma formation with direct hernia repairs when the lax transversalis fascia (TF) is inverted by tacking to the pubic ramus. We undertook a study to investigate whether TF inversion in this way reduces the incidence of postoperative seroma. Method A total of 216 patients undergoing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs from August 2003 to December 2005 were included in this prospective non-randomised controlled study. Surgeon 1 would routinely invert the TF whereas surgeon 2 would not. At follow-up the presence of postoperative seroma and pain was recorded. Results Mann–Whitney U test demonstrated no significant difference in terms of age, sex and time to follow-up between the surgeons’ patient groups (P > 0.05), and Chi-square test demonstrated significantly that inversion of the TF is associated with a lower incidence of postoperative seroma (P < 0.05). There was no significant difference in terms of postoperative pain at follow-up. Conclusion Inversion of the TF is associated with a statistically lower incidence of postoperative seroma, without increasing postoperative pain despite the use of one or two additional tacks.     

Preperitoneal repair for recurrent inguinal hernia: Laparoscopic and open approach

Background: The aim of this study was to investigate the outcome of preperitoneal repair using laparoscopic (TEP) and open (OPM) approach in recurrent inguinal hernia. Methods: We performed a prospective controlled nonrandomized clinical study in 188 patients with 207 recurrent inguinal hernias over a period of 5 years. TEP repair was employed for 86 repairs, and OPM was used in 121 procedures. The main outcome measurements were: recurrence rate, operating time, hospital stay, and postoperative complications. Results: There were three recurrences (1.7%). Two in the OPM group (1.8%) and one (1.3%) in the TEP group [P=NS (not significant)]. The TEP procedure was faster than OPM for unilateral repair (40.8 vs 46.3 min) (P<0.001). Postoperative complications were more frequent in the OPM group (23.9%) than the TEP group (13.9%) (P=NS). Hospital stay was significantly shorter in the TEP group (1.2 vs 3.9 days) (P<0.001). Conclusions: Preperitoneal approach (open or laparoscopic) seems to be a good option in recurrent inguinal hernia when these procedures are done by experienced surgeons.     

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目的总结1997年11月至2011年12月复旦大学附属华东医院开展开放式腹股沟疝无张力修补术4438例的临床经验。方法根据各种不同类型的开放式腹股沟疝无张力修补术,对4438例腹股沟疝采用相对应的不同补片进行手术治疗,对不同术式的手术时间、术后疼痛、疝复发、血肿、血清肿、慢性疼痛、生殖系统并发症等及其他相关并发症进行观察、总结及数据分析。结果无手术死亡病例。术后平均随访33.7个月,术后血肿18例(0.40%),血清肿45例(1.01%),切口感染或愈合不良16例(0.40%),缺血性睾丸炎3例(0.07%)。复发14例(0.32%),慢性疼痛7例(0.60%),异常勃起1例(0.02%);3例睾丸疼痛(0.07%)。结论开放式无张力疝修补术治疗腹股沟疝安全有效,不同术式的疗效及并发症发生率情况接近,开展技术早期需特别注意预防手术并发症,对不同的病例宜采用个体化治疗方案,以期达到最佳的治疗效果。     

腹腔镜腹股沟疝修补术216例临床分析

目的:探讨腹腔镜腹股沟疝修补术的疗效及可行性。方法:216例249侧腹股沟疝用腹腔镜行疝修补术,全部经腹腔修补。其中腹股沟斜疝191例207侧,腹股沟直疝25例42侧。结果:手术均获成功,手术时间70～120min,平均90min。术后平均住院5d。随访162例,1例复发,复发率0.46%。结论:腹腔镜疝修补术具有患者康复快、疗效好、复发率低、疼痛轻等优点,值得推广应用。     

Laparoscopic bilateral inguinal hernia repair under local anesthesia

A case report of the laparoscopic repair of bilateral inguinal hernias performed under local anesthesia with intravenous sedation is presented. The combination of nitrous oxide for peritoneal insufflation and an ultrasonically activated scalpel for dissection made the procedure feasible. It is hoped that this technique can extend laparoscopic surgery to patients who are poor candidates for general anesthesia.     

超声引导下聚桂醇注射在腹腔镜腹股沟疝修补术后血清肿中的应用

目的 观察超声引导下聚桂醇注射治疗腹腔镜腹股沟疝修补术后血清肿的效果.方法 选取徐州医科大学附属医院普外科2016年5月至2019年11月腹腔镜腹股沟疝修补术后并发血清肿、术后1个月仍未消退(Ⅱ型及以上血清肿)病人15例,彩超引导下抽空液体后注入聚桂醇后疝气带局部加压包扎.结果 15例病人中13例1次注射后治愈,2例1...     

Laparoscopic extraperitoneal inguinal hernia repair in the day-care setting

Background: Totally extraperitoneal (TEP) laparoscopic inguinal hernia repair is gaining popularity, and our preference is to perform this procedure as a day case. This study evaluates the suitability of TEP repair in the day-care setting. Methods: A policy of day-care TEP repair, unless contraindicated, was adopted for inguinal hernia repair, and the outcome was prospectively evaluated. Of 87 consecutive inguinal hernia repairs, day-care TEP was possible in 54 (62%); 17 (20%) were in-patient TEP, 14 (16%) were open repairs, and 2 (2%) were converted from TEP to open repairs. Results: Among day-care TEP repairs, median visual analog pain score at discharge was 2.3/10, and 43% of patients had no pain. Complications included cord hematoma 2 (4%) and seroma 3 (6%). Median times for stopping analgesia, resumption of full activity, and return to work were 3, 3, and 6 days respectively. Complete satisfaction with day-care TEP was expressed by 91% of patients; 9% were moderately satisfied, and none expressed dissatisfaction. Conclusions: Day-care TEP repair is feasible in the majority of patients with inguinal hernias, and it is associated with minimal complications, excellent recovery, and a high degree of patient satisfaction. Received: 25 February 1998/Accepted: 28 May 1998     

Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias

BACKGROUND: This study was designed to investigate age, sex, and side of hernia presentation at clinical examination as potential intrinsic risk factors for bilateral inguinal hernia (BIH), and to quantify the characteristics of clinical examination versus laparoscopy as a diagnostic tool for BIH. METHODS: A cross-sectional study was utilized to analyze 99 consecutive patients undergoing laparoscopic inguinal hernia repair. RESULTS: The incidence of BIH based on clinical examination alone was 49%, compared with 71% laparoscopically. Clinical examination of BIH resulted in 69% sensitivity, 100% specificity, 100% predictive value for bilateral diagnosis, and 57% predictive value for unilateral diagnosis. Left hernia presentation at clinical examination (prevalence rate ratio = 10.5, 95% confidence interval: 3.6 to 30.7) and male sex (prevalence rate ratio = 6.6, 95% confidence interval: 1.3 to 35.0) were found to be independent risk factors for BIH. CONCLUSIONS: Laparoscopy yields detection of BIH that would be missed by clinical examination alone. Furthermore, left-sided hernia and male sex were associated with BIH.     

Laparoscopic inguinal hernia repair in the pediatric age group—experience with 437 children

Background/Purpose

A retrospective analysis of prospectively collected data of pediatric patients that underwent laparoscopic inguinal hernia repair.

Material and methods

A retrospective review was performed of the prospectively collected data of 576 laparoscopic internal ring closures in 437 children (age, 30 days-11 years; median, 1.9 years) from June 1999 to February 2009. The internal ring was closed with a 3-0 nonabsorbable suture. Both extracorporeal and intracorporeal methods of knotting were used. All patients were asked to return at 1 week and 6 weeks postoperatively for routine follow-up.

Results

A contralateral patent processus vaginalis was present in 13% (45/352) of boys and 15% (12/83) of girls on the right side, and 7% (25/352) of boys and 6% (5/83) of girls on the left side. Follow-up range was from 1 week postoperatively to 108 months. There were 14 recurrences (2.4 % [14/576], 11 in boys and on the right side and 3 in girls) and 2 hydroceles 0.35% (2/576). Mean operating time was 23 minutes for unilateral and 29 minutes for bilateral inguinal hernia. There was neither metachronus hernia nor testicular atrophy observed during follow-up.

Conclusion

Laparoscopic inguinal hernia repair is technically easier, as there is no need to dissect the vas deferens and vessels. The risk of metachronous hernia is reduced, and we believe the cosmetic result is better. Although recurrences were more common early in the series, currently they are much less frequent. Laparoscopic inguinal hernia repair appears to have less morbidity than open herniotomy and can be used as routine procedure in the pediatric age group.     

Pediatric inguinal hernia: laparoscopic versus open surgery

BACKGROUND AND OBJECTIVES: Herniotomy/open surgery (OS) has been the time honored treatment for pediatric inguinal hernia (PIH). Laparoscopic surgery (LS) has recently emerged as an alternative in its management. However, controversy is rife on its feasibility and wider adoption. The present need is to know whether a significant difference exists in the surgical outcomes following either technique. METHODS: In a prospective study between January and December 2006, 85 children underwent either LS (51) or OS (34) for PIH. Operation time, intra- and postoperative complications, postoperative pain, postoperative stay, cosmesis, and the size of testis were recorded and compared for differences in outcome. Patients were followed up for an average of 3.5 months. RESULTS: All in the open group had unilateral (UL) hernias. The laparoscopy group had 6 (11.8%) bilateral (BL) hernias, and 10 (22.2%) contralateral patencies of processus vaginalis (CPPV) were detected intraoperatively and repaired simultaneously. Bilateral repairs were excluded from comparative analysis. LS was slightly quicker than OS to perform [25.31 min vs 30.65 min (P=0.06)]. The difference in pain perception, between LS and OS, was insignificant. Immediate postoperative recovery was delayed in more children undergoing LS (P=0.02), but the duration of hospital stay was similar (P=0.37). Complication rates were similar (P=0.96). Cosmesis in LS was superior to that in OS. CONCLUSIONS: Well-performed conventional herniotomy yields results similar to those of laparoscopic repair. Cosmesis and the ability to detect and simultaneously repair CPPV are the 2 main advantages of LS over OS. Keeping in mind the low incidence of meta-chronicity in UL hernias, insignificance of cosmesis over the groin, and the constraints of the developing world, conventional open herniotomy can justly be performed for UL hernias, as the standard of care, in centers lacking laparoscopy.